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I’m wary to entertain that there is a debate on this or that it’s a “theory”. It’s like debating a theory that the Easter Bunny causes mental illness–if the onus is on me to prove that the Easter Bunny does not, in fact, cause mental illness, I must admit I have no proof she’s not responsible. So does that mean the theory remains undefeated?

The chemical imbalance myth pops up frequently, even from the mouths of healthcare professionals, and it can get in the way of people accessing actual evidence-based supports to overcoming mental illness. I got asked on Twitter recently about chemical imbalances so I’ll share my responses here and offer some additional context.

I struggled with a broad range of mental illness symptoms, including the fantastically paranoid and delusion variety. Here’s a video describing some of the issues I overcame around paranoia: Paranoia & Being Watched and that’s only a tiny glimpse of what I was dealing with. I didn’t have some traumatic experience in my past that caused these issues, either. Getting over this didn’t involve taking any medication or supplements or any stuff of any kind. I had to learn new skills. I had to learn different ways of thinking and behaving, learning how to experience thoughts and emotions while making choices that were healthy for me and those around me.

One of the reasons I got into the work I do now is because I was so surprised by the gap between where the scientific research was at for helping people recover from mental illness (we know how to help people overcome mental illness) and where the popular perception of mental illness is at (as this chronic beast you just try to sedate and manage).

Pharmaceutical companies often get blamed for the chemical imbalance myth and you could argue they might have started it, but I’d say it’s healthcare professionals, mental health organizations, and patients that keep it going. As mentioned in the article I tweeted, pharma companies aren’t investing in new psych drugs and they’ll readily admit there’s unappealing levels of risk when investing massive sums of money in a drug that’s unlikely to beat the placebo once clinical trials start. There is nothing strange about companies continuing to sell psych meds they know work no better than a placebo; people keep demanding them and doctors keep prescribing them. They prescribe them for all sorts of things other than mental health issues and keep prescribing well beyond suggested guidelines, which only makes it more difficult to stop taking them, and perpetuates the belief that people need to keep taking the drugs to fix some sort of permanent imbalance.

The number of people with mental illnesses that experience a placebo response and the number of people that experience no response from psych meds (other than the side effects) should be enough to put a nuclear torpedo into the chemical imbalance myth. However, meta-analyses like this one: “Antidepressant drug effects and depression severity: a patient-level meta-analysis.” suggest that SSRIs are more effective if the symptoms are more severe. That could suggest that there is a group of patients with more severe mental illness issues who are experiencing “chemical imbalances”. That wouldn’t mean the chemical imbalances caused the mental illness. They could be a result of the illness, in the same way people that don’t exercise will have measurably different things happening in their bodies compared to people that do. But there’s still an imaginary catch…

In this article on deep brain stimulation “A Shocking Way to Fx the Brain”, there’s a key tidbit of information about the first studies done to get FDA approval for brain implants to help people with treatment resistant mental illnesses: “After analyzing preliminary results, the FDA halted both trials. ‘We ended up having a fairly high placebo effect.'”

We’ve got a serious placebo problem that mental health advocates and professionals need to get honest about. The patients enrolled in those Deep Brain Stimulation trials had to qualify as having uniquely difficult mental illnesses to treat. They were supposed to be on the extreme end of the spectrum. They’d tried every treatment available and now they were willing to have somebody drill a hole in their heads and become cyborgs to short-circuit a part of their brain. But enough people in the placebo group got better that the trials got cancelled. If mental illnesses are chemical or structural problems in the brain requiring medical intervention, how could any patient with a severe mental illness see results without doctors modifying any chemicals or structures (besides the hole in the skull)?

The idea of balancing humors in the body was influential over Western medicine into the 1800s and arguably even more influential during the advent of modern psychiatry. One example of this is hysteria–the wandering womb that caused women emotional issues. That wandering womb was “caused by moral and physiological imbalances”. When you look back at how the idea of physiological imbalances has played out over the years, you see how it’s been consistently used as a tool to oppress people. I find it so strange when mental health advocates are bringing up myths about imbalances because these myths have always been used as excuses to exclude people and lock them up and keep them dependent on the systems that invent the imbalances.

But it’s not that strange that a myth from 1900 BC persists in contemporary medicine. The diagnosis of “hysterical neurosis” only got deleted in 1980 from the DSM (the book outlining the American Psychiatric Association’s mental illness diagnoses). Let that sink in: It was only in the 80s that we ditched a belief about mental illness that was over 3000 years old. Sacrifice a lamb and hope everything resolves itself!

As science was moving away from the chemical imbalance myth, we decoded the human genome, and suddenly we had a new simple solution to everything in our heads: The gene imbalance myth.

Blaming neurotransmitters for all of our mental ills evolved into blaming the genes responsible for our neurotransmitters. In particular, the short allele of the serotonin transporter promoter gene polymorphism (5-HTTLPR) got singled out as the “depression gene”. This spawned numerous blog posts and articles by journalists getting their DNA tested and confirming, as they’d always suspected, they were genetically predisposed to being a miserably anxious writer stumbling from one precarious writing gig to the next. Being in possession of the short allele of the gene basically meant a person would produce fewer transporter proteins to carry the serotonin where it needed to go. Finally, research on genes supported the belief that chemical imbalances were responsible for mental health issues! Lack of serotonin was the problem!

Not so fast there…

There’s a bias you’ll often find in mental illness research: it sees the world as made up of two groups of people: the mentally ill and everybody else. This leads to studies that basically go like this: 1) Get a bunch of sick people together. 2) Compare their data to everybody else. 3) Find commonalities amongst the sick people and declare that the cause of their illness. But looking at mentally ill people and non-mentally ill people is not the same as looking at mentally ill people and mentally healthy people. And it’s by looking at mentally healthy people that the gene imbalance theory began to fall apart because, it turns out, you’re as likely to have poor mental health with the short allele of the serotonin transporter gene as you are to have great mental health. It’s your life experiences that determine how things unfold. This article “Gene magnifies psychological impact of life experiences, for better and for worse” (which still called it the “depression gene”–come on journalists!) explains research that showed kids with the short allele and a history of trauma or abuse were more likely to experience poor mental health, while kids with the same gene variant that didn’t have similar traumatic experiences, went on to be happier than the general population. But as this study highlights, poor mental health is not inevitable for a child with the short allele if they receive support. This article in Nature suggest we shouldn’t see genes like 5-HTTLPR as “vulnerability genes” but instead as “plasticity genes”–they make your nature predisposed to nurture. If you’re around mentally healthy people, you pick up their skills. If you’re around mentally unhealthy people, you pick up their skills.

When we’re talking about chemical imbalances, I often hear people say things like: “Ok, maybe depression isn’t an imbalance, but what about serious mental illnesses like schizophrenia?” But people with experience of psychosis have led the recovery movement for years. Learning new skills to handle experiences like hearing voices is a more effective long-term solution than trying to cover up those experiences with drugs, and the research is now showing that medication-only approaches to psychosis lead to worse long-term outcomes and more episodes of psychosis. Check out this overview of the research from the former director of the National Institute for Mental Health, the world’s largest funder of mental health research (not exactly a fringe science organization): “Antipsychotics: Taking the Long View” Again, if antipsychotics were correcting an imbalance, why do the people that continue taking the antipsychotics have worse outcomes than those that get help to discontinue them?

Speaking of plasticity: instead of creating a balance, recent research suggests that drugs like SSRIs or SNRIs could be more like steroids–they’re creating imbalances, not fixing them, but that imbalance could be useful to you. However, if they are stimulating neurogenesis (animal models suggest that’s the case), changing ways of thinking and behaving are still important–you don’t want to get stuck with the same brain that got you into this mess!

When “hysteria” was a thing, doctors believed you could use strong odours, like smelling salts, to scare the womb back to it’s “correct” position. If you go to a doctor (today) with a mental health issue and all they prescribe for you is medication, they’re stuck in that same approach, trying to scare away emotions. We have evidence-based, thoroughly researched approaches to helping people accept the stuff in their heads and recover completely from mental illness. You don’t have to demonize emotions. We improve our mental health in the same way we improve our physical fitness–by pushing into challenging experiences and developing skills to handle them.

You have many choices to make. We need to enable you to access support for those choices. But you don’t have a chemical imbalance.

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6 Comments

I kind of agree with you. I have OCD and I think I am improving (am I? Well, that’s OCD) without medication. I did take it for 5 months but when I noticed that it wasn’t helping me at all I quit taking it,against the advice of my doctor. The doctor I was seeing was hell bent upon prescribing medication (she even prescribed a very low dose of antipsychotics). But she is a senior doctor and has a long experience. However i dont know how god she was with OCD. To her credit, she told me that medication alone wouldn’t cure me, therapy is needed but the medication would help it. I tool it for 5 long months waiting for when the therapy would start and all she did was increasing the dosage. The interesting thing is I always knew that there is a critical error in my thinking that needed to be resolved. I was just getting too scared of my thoughts and all I needed was someone to tell me what’s exactly wrong and lay it out for me. But thanks to your and a lot of other people’s videos, I have begun to understand what it is and where I was going wrong.

Mark, great article….how would you suggest dealing with benzodiazepine withdrawals that cause intense discomfort and spike OCD intrusive thoughts — specifically going crazy and harming myself or someone else? I know ERP is the gold standard, but how it do ERP when some of those calming receptors have been damaged and the natural calming mechanism is broken. Thanks

Thanks, Tim. In terms of types of therapy, you might find it useful to try out Acceptance & Commitment Therapy (ACT). It’s got the same practices as in ERP–cutting out compulsions and doing things you value–but I find that there are added tools in ACT that are especially useful for learning how to accept difficult physical experiences along with difficult emotional experiences. Something else I found really useful was exploring unhelpful beliefs I had around the idea of “calm”. If we get caught up thinking that we need to be calm and that not being calm is wrong or a problem to fix, then it’s very natural to create lots of anxiety for ourselves. But that’s because of that belief that we should be experiencing something. It’s not a problem with the actual experience. Learning how to be ok with what I’m experiencing right now and making a choice from here, not trapping myself in a cage of shoulds and shouldnots was extremely freeing. Enjoy the steps out of the cage!